Top Care and Coverage Dilemmas

Consumers appear to be struggling more with worries about access to health care, while even those with coverage are running into barriers to getting some treatments authorized by insurers. And many Americans have questions about the workings of the federal health-overhaul law.

ENLARGE

Jason Raish

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Those are among the findings in a new report released by the Patient Advocate Foundation, a nonprofit that works with consumers to resolve problems with health costs and coverage.

Each year, the group puts out a compilation of its cases—a total of 109,147 in 2012—that provides something of a snapshot of Americans' gripes and dilemmas related to health insurance, medical bills and disabilities.

Because the foundation focuses mostly on those with serious health issues, its data are tilted toward that population's concerns, rather than the day-to-day billing and other snafus that many encounter in the medical system. Among the top conditions suffered by patients that the nonprofit served were cancer, diabetes and cardiac disease. A little over one-third of them were uninsured, but 31% had commercial coverage and 23% were Medicare beneficiaries in 2012.

Broadly, among all the foundation's patients, the biggest category of concerns had to do with debt problems and cost-of-living struggles. That category includes problems affording services like transportation and rent as well as medical costs.

Among the most striking trends in 2012, according to Beth Patterson, the foundation's president of mission delivery, was a seeming uptick in the number of issues involving access to care—meaning that patients had difficulties getting treatment for a condition from a doctor or hospital. In some cases, this may have reflected a shortage of health-care providers, and in other cases they were requiring upfront payment before they offered care, Ms. Patterson says.

In the past, she adds, the patients were more likely able to receive care, though they may have grappled later with the bills.

Problems of access affected even those with coverage, according to the foundation. Ms. Patterson notes an uptick among those with commercial insurance who ran into denials of pre-authorization from an insurer for a treatment. Some also faced refusals for coverage of second opinions. (The foundation worked on appeals of such denials as well as of situations where a plan had excluded a treatment as a noncovered benefit.)

Insurers seem to be "applying more restrictive policies to the pharmaceutical side than they have before," Ms. Patterson says.

Commercially-insured patients also struggled with out-of-pocket charges, which generally are going up. The share of workers with single-person employer coverage including deductibles of $1,000 or more hit 34% last year, according to an annual survey conducted by the Kaiser Family Foundation and the Health Research & Educational Trust. That was up from 31% the year before and 12% in 2007. The survey also found that drug coverage is including more "tiers," or levels of copayment, where the highest tier comes with the highest charge to patients: 14% of plans had four or more tiers last year, and 63% had three.

Indeed, 16.3% of the patient foundation's commercially-insured patient cases involved drug copayments, and copay assistance generally was the most common type of help it offered them. Deductible assistance was number six on the list.

Among Medicare beneficiaries, copay help for medical treatment represented around 18% of cases, while drug copay aid was 21%. The need for assistance paying for pharmaceuticals was down a bit, however, as the health law is filling in the "doughnut hole" gap in coverage within Medicare, Ms. Patterson says. The foundation also helped negotiate payment plans and discounts for Medicare patients and helped them get supplemental coverage.

Also, a number of people contacted the foundation with questions about the federal health-care law. The biggest group was patients looking for help enrolling in the law's plans for people with pre-existing health conditions. Around a third of individuals simply had general questions about the law.

Another big topic for questions was the law's requirement that insurers sell plans to people even if they have existing health problems. This requirement doesn't fully kick in until 2014.

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